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cancer de seno metastasico
cancer de seno metastasico
cancer de seno metastasico
cancer de seno metastasico
cancer de seno metastasico
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cancer de seno metastasico
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cancer de seno metastasico

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  • 1. VOLUME 29 ⅐ NUMBER 9 ⅐ MARCH 20 2011 JOURNAL OF CLINICAL ONCOLOGY A S C O S P E C I A L A R T I C L E American Society of Clinical Oncology Executive Summary of the Clinical Practice Guideline Update on the Role of Bone-Modifying Agents in Metastatic Breast Cancer Catherine H. Van Poznak, Sarah Temin, Gary C. Yee, Nora A. Janjan, William E. Barlow, J. Sybil Biermann, Linda D. Bosserman, Cindy Geoghegan, Bruce E. Hillner, Richard L. Theriault, Dan S. Zuckerman, and Jamie H. Von RoennFrom the University of Michigan, AnnArbor, MI; American Society of Clinical A B S T R A C TOncology, Alexandria; Virginia Common-wealth University, Richmond, VA; Univer- Purposesity of Nebraska Medical Center, Omaha, To update the recommendations on the role of bone-modifying agents in the prevention andNE; Cancer Research and Biostatistics, treatment of skeletal-related events (SREs) for patients with metastatic breast cancer withSeattle, WA; Wilshire Oncology Medical bone metastases.Group, Rancho Cucamonga, CA; Y-MENational Breast Cancer Organization; Lurie MethodsComp Cancer Center of Northwestern A literature search using MEDLINE and the Cochrane Collaboration Library identified relevantUniversity, Chicago, IL; National Center for studies published between January 2003 and November 2010. The primary outcomes of interestPolicy Analysis, Dallas; The University of were SREs and time to SRE. Secondary outcomes included adverse events and pain. An UpdateTexas MD Anderson Cancer Center, Hous- Committee reviewed the literature and re-evaluated previous recommendations.ton, TX; and Mountain States Tumor Insti-tute, Boise, ID. ResultsSubmitted September 3, 2010; accepted Recommendations were modified to include a new agent. A recommendation regarding osteo-January 13, 2011; published online ahead necrosis of the jaw was added.of print at www.jco.org on February 22, Recommendations2011. Bone-modifying agent therapy is only recommended for patients with breast cancer with evidenceBoard Approved: December 2, 2010. of bone metastases; denosumab 120 mg subcutaneously every 4 weeks, intravenous pamidro-Editor’s Note: This represents a brief nate 90 mg over no less than 2 hours, or zoledronic acid 4 mg over no less than 15 minutes everysummary overview of the complete Ameri- 3 to 4 weeks is recommended. There is insufficient evidence to demonstrate greater efficacy ofcan Society of Clinical Oncology (ASCO) one bone-modifying agent over another. In patients with a calculated serum creatinine clearanceClinical Practice Guideline Update and of more than 60 mg/min, no change in dosage, infusion time, or interval of bisphosphonateprovides the updated recommendations administration is required. Serum creatinine should be monitored before each dose. All patientswith brief discussions of the relevant litera-ture for each. The complete guideline, should receive a dental examination and appropriate preventive dentistry before bone-modifyingwhich includes comprehensive discussions agent therapy and maintain optimal oral health. Current standards of care for cancer bone painof the literature, methodology information, management should be applied at the onset of pain, in concert with the initiation of bone-and all cited references, plus a data supple- modifying agent therapy. The use of biochemical markers to monitor bone-modifying agent use isment with evidence tables the Update not recommended.Committee used to formulate theserecommendations, are available atwww.asco.org/guidelines/bisphosbreast. bone-modifying agents as adjuvant treatment of INTRODUCTIONCorresponding author: American Society of breast cancer and in managing treatment-associatedClinical Oncology, 2318 Mill Rd, Suite 800, The American Society of Clinical Oncology (ASCO) bone loss. Please note that the term bisphosphonateAlexandria, VA 22314; e-mail: guidelines@asco.org. first published evidence-based clinical practice in specific recommendations used in 2003 (Recom-© 2011 by American Society of Clinical guidelines for use of bisphosphonates in breast can- mendations 1, 2, 4, 6, and 7) has been changed to theOncology cer in 2000.1a ASCO previously updated these guide- term bone-modifying agent.0732-183X/11/2909-1221/$20.00 lines on bisphosphonates in breast cancer in 2003.1bDOI: 10.1200/JCO.2010.32.5209 Reflecting the Update Committee’s recognition of Update Type new types of agents, including osteoclast inhibitors This guideline is an update. This type of update such as denosumab, and others that may be available is one in which a systematic review found some new for future updates of this guideline, this guideline evidence and, consequently, some recommenda- uses the term bone-modifying agents. tions were changed or added.1c The majority of the As a result of changes in the field, the scope of recommendations are the same as in the 2003 guide- this guideline has been narrowed to the use of lines for metastatic breast cancer. No additional data bone-modifying agents for patients with metastatic are available with regard to the dose, dose interval, or breast cancer. A separate update will cover the role of duration of therapy of bone-modifying agents. The © 2011 by American Society of Clinical Oncology 1221 Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
  • 2. Van Poznak et alcurrent guideline has added a recommendation regarding osteo- the English-language literature from January 2003 to July 15, 2009,necrosis of the jaw (ONJ), a condition recognized after the devel- were conducted to address each of the original guideline questions;opment of the 2003 guidelines. This guideline on metastatic breast subsequently, additional searches on adverse events were conducted.cancer also reviews data on a new bone-modifying agent, deno- An additional search for randomized controlled trials (RCTs) reportingsumab. There are new data on the bisphosphonate ibandronate. efficacy and case-control or cohort studies on adverse events publishedHowever, the US Food and Drug Administration (FDA) has not between July 2009 and November 2010 was conducted. Specific num-approved ibandronate for use in patients with breast cancer meta- bers of studies found in the literature search, the literature search terms,static to the bone at the time of publication. For each of the and a QUORUM diagram are available online in the guideline andrecommendations, clinical judgment should also take into consid- Data Supplements 4 and 5 at www.asco.org/guidelines/bisphosbreast.eration the patient’s general performance status, patient prefer-ences, and overall prognosis. Inclusion/Exclusion Criteria Articles were selected for inclusion if they met the following METHODOLOGY criteria: participants had metastatic breast cancer and were randomly assigned to receive a bone-modifying agent or placebo or an alterna-This guideline was reviewed and approved by the Journal of Clinical tive intervention. Outcome measures for efficacy and adverse eventOncology and the ASCO Clinical Practice Guidelines Committee and studies included at least one of the following: skeletal-related eventsthe Board of Directors. (SREs) and time to SRE, adverse events, pain, and quality of life (see Definition of Terms). Searches for efficacy outcomes were limited toLiterature Search Strategy published phase III RCTs, systematic reviews, and meta-analyses. For For this guideline, computerized literature searches of MEDLINE adverse events, the search was broadened to include case-control andand the Cochrane Collaboration Library were conducted. Searches of cohort studies. THE BOTTOM LINE ASCO GUIDELINE UPDATE The Role of Bone-Modifying Agents (BMAs) in Metastatic Breast Cancer Intervention ● Bone-modifying agents (BMAs), including bisphosphonates Target Audience ● Medical Oncologists, Radiation Oncologists, Surgical Oncologists, Palliative Care Providers Key Recommendations ● BMAs are recommended for patients with metastatic breast cancer with evidence of bone destruction. ● Denosumab 120 mg subcutaneously every 4 weeks; intravenous (IV) pamidronate 90 mg over no less than 2 hours every 3 to 4 weeks; or IV zoledronic acid 4 mg over no less than 15 minutes every 3 to 4 weeks ● One BMA is not recommended over another. ● In patients with creatinine clearance Ͼ 60 mL/min, no change in dosage, infusion time, or interval is required; monitor creatinine level with each intravenous bisphosphonate dose. ● In patients with creatinine clearance Ͻ 30 mL/min or on dialysis who may be treated with denosumab, close monitoring for hy- pocalcemia is recommended. ● All patients should have a dental examination and preventive dentistry before using a BMA. ● At onset of cancer bone pain, provide standard of care for pain management and start BMAs. ● Use of biochemical markers to monitor BMA use is not recommended for routine care. Methods ● Systematic review of medical literature and analysis of the medical literature by the Update Committee of an Expert Panel Additional Information ● The recommendations, clinical questions, and a brief summary of the literature and discussion are in this Executive Summary. The full guideline, with comprehensive discussions of the literature, methodology, full reference list, evidence tables, and clinical tools and resources, can be found at www.asco.org/guidelines/bisphosbreast.1222 © 2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
  • 3. Breast Cancer Bone-Modifying Agents Update Executive SummaryDefinition of Terms skeletal morbidity period rate. Both the IV and oral formulations of Most clinical trials define an SRE as fracture (pathologic, verte- ibandronate are approved for use in this setting in some countriesbral, and/or nonvertebral), radiation therapy to bone, surgery to bone, outside the United States.and spinal cord compression. The definition may or may not include The guideline reviews data on a new agent, denosumab, a fullyhypercalcemia of malignancy. human monoclonal antibody to receptor activator of nuclear factor- Skeletal morbidity period rate is the number of 12-week periods ␬-␤ ligand. Because ibandronate is not approved by the FDA, thewith new skeletal complications, divided by the total observational recommendation did not change to specify its use. There are no newtime. Skeletal morbidity rate is the number of SREs per year. Multiple- reports on clodronate in the metastatic bone disease setting.event analysis is an analysis of data on all clinically relevant SREs andtime to each event. Clinical Question 2 What is the role of bone-modifying agents in the presence ofGuideline Policy extraskeletal metastases without evidence of bone metastases? This Executive Summary for physicians is an abridged summary Literature update and discussion. This recommendation remainsof an ASCO௡ practice guideline. The practice guideline and this sum- unchanged from 2003. There have been no new clinical trials reportedmary are not intended to substitute for the independent professional with patients with breast cancer with extraskeletal metastases but whojudgment of the treating physician. Practice guidelines do not account do not have evidence of bone metastases.for individual variation among patients and may not reflect the mostrecent evidence. This summary does not recommend any particular Clinical Question 3Aproduct or course of medical treatment. Use of the practice guideline and What are the renal safety concerns of bone-modifyingthis summary is voluntary. The full practice guideline and additional agent therapy?information are available at www.asco.org/guidelines/bisphosbreast. Literature update and discussion. Pamidronate and zoledronic acid are associated with renal deterioration, particularly in patientsGuidelines and Conflict of Interest with pre-existing renal impairment and in those who receive multiple The Update Committee was assembled in accordance with cycles of bisphosphonate therapy. This recommendation was changedASCO’s Conflict of Interest Management Procedures for Clinical to reflect the new dosing guidelines for patients with pre-existing renalPractice Guidelines (“Procedures,” summarized at www.asco.org/ impairment added to the zoledronic acid package insert in Januaryguidelinescoi). Members of the Update Committee completed AS- 200512 and the availability of the new bone-modifying agent, deno-CO’s disclosure form, which requires disclosure of financial and other sumab. The zoledronic acid package insert recommends a lower initialinterests that are relevant to the subject matter of the guideline, includ- zoledronic acid dose (ranging from 3.0 to 3.5 mg) depending on theing relationships with commercial entities that are reasonably likely to estimated creatinine clearance. No similar dosing guideline exists forexperience direct regulatory or commercial impact as the result of pamidronate. The FDA-approved label for denosumab does not spec-promulgation of the guideline. Categories for disclosure include em- ify a need for dose adjustment for renal safety.13ployment relationships, consulting arrangements, stock ownership, In addition to the package inserts for denosumab, zoledronichonoraria, research funding, and expert testimony. In accordance acid, and pamidronate, the evidence reviewed for this recommenda-with the Procedures, the majority of the members of the Update tion included four RCTs, a safety extension of one of those RCTs, andCommittee did not disclose any such relationships. a retrospective cohort study. Pamidronate and zoledronic acid should be withheld from pa- tients developing renal deterioration as defined in the package inserts. RESULTS Once serum creatinine returns to within 10% of baseline, therapy can be resumed. The FDA label states that zoledronic acid therapy shouldTable 1 lists the recommendations from the 2003 guideline and the be reinitiated at the same dose as that before treatment interruption.2011 guideline update. Ibandronate may have a different renal safety profile than pamidro- nate and zoledronic acid; however, no definitive conclusions aboutClinical Question 1 their comparative safety can be reached. Data on the long-term renal What are the indications for using bone-modifying agents to safety of bone-modifying agents are limited.reduce the risk of SREs in patients with metastatic breast cancer? When The Update Committee agrees with the FDA package insert di-is the best time to initiate treatment with bone-modifying agents? rections for use of denosumab, pamidronate, and zoledronic acid, Literature update and discussion. This recommendation was including the monitoring of laboratory parameters, dose, and infusionchanged from 2003 because of the results of trials of a new bone- times. The Update Committee encourages health care providers to bemodifying agent. The studies reviewed for this guideline were phase II active in reporting postmarketing safety concerns and to review thetrials, phase III trials, and follow-up studies of phase III clinical trial FDA labeling and Web sites for updates.results on denosumab (two phase II trials2,3 and one phase III trial4), Follow-up from the zoledronic acid versus pamidronate studiesibandronate (two phase III trials/analyses of oral ibandronate5,6 and have not changed the 2003 guideline’s conclusion that the safety of thetwo phase III trials of intravenous [IV] ibandronate7,8), pamidronate two agents seems to be similar with respect to nonrenal adverse events.(in the follow-up studies of the phase III zoledronic acid trial9,10 and as Ibandronate may have a slightly higher risk of GI adverse effects thana comparator in two phase II trials2,3), and zoledronic acid (two zoledronic acid or placebo and higher arthralgia than placebo. Deno-follow-up studies of a phase III trial9,10 and two new RCTs4,11). These sumab had a lower rate of arthralgia, asthenia, and acute-phase reac-trials found that all four agents reduce SREs, the time to SRE, and tions than zoledronic acid and a higher rate of hypocalcemia. Patientswww.jco.org © 2011 by American Society of Clinical Oncology 1223 Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
  • 4. Van Poznak et al Table 1. Summary of 2011 Recommendations Recommendation Category 2003 Recommendations 2011 Recommendations Change Recommendation 1: For breast cancer patients who have evidence of bone For patients with breast cancer who have evidence of bone metastases, Addition of new bone-modifying agent. Indications and time destruction on plain radiographs, IV pamidronate 90 denosumab 120 mg subcutaneously every 4 weeks, IV Term changed from bisphosphonates of initiation mg delivered over 2 hours or zoledronic acid 4 mg pamidronate 90 mg delivered over no less than 2 hours, or zoledronic to bone-modifying agents. over 15 minutes every 3 to 4 weeks is acid 4 mg over no less than 15 minutes every 3 to 4 weeks is recommended. Starting bisphosphonates in women recommended. Starting bone-modifying agents in women with an with an abnormal bone scan and an abnormal CT or abnormal bone scan and an abnormal CT scan or MRI showing bone MRI scan showing bone destruction, but normal destruction, but normal plain radiographs, is considered reasonable by plain radiographs, is considered reasonable by Panel consensus based on the findings in women with lytic or mixed Panel consensus based on the findings in women lytic/blastic changes on plain radiographs. Starting bone-modifying with lytic or mixed lytic/blastic changes on plain agents in women with only an abnormal bone scan but without radiographs. There is insufficient evidence relating evidence of bone destruction on radiographs, CT scans, or MRI is not to efficacy to support one bisphosphonate over the recommended outside of a clinical trial. There is insufficient evidence other. For each of the guidelines, clinical judgment relating to efficacy to support one bone-modifying agent over another. should also take into consideration the patient’s general performance status and overall prognosis. Recommendation 2: Role of Starting bisphosphonates in women without evidence Starting bone-modifying agents in women without evidence of bone (Unchanged in substance from 2003) bone-modifying of bone metastases even in the presence of other metastases even in the presence of other extraskeletal metastases is Term changed from bisphosphonates agents in the extraskeletal metastases is not recommended. This not recommended. This clinical situation has been inadequately to bone-modifying agents. presence of clinical situation has not been studied using IV studied using IV bisphosphonates or other bone-modifying agents and extraskeletal bisphosphonates and should be the focus of new should be the focus of new clinical trials. metastases clinical trials. Starting bisphosphonates in women with only an abnormal bone scan but without evidence of bone destruction on radiographs, CT scans, or MRI is not recommended. Recommendation 3A: Renal In patients with pre-existing renal disease and a serum In patients with a calculated serum creatinine clearance > 60 mL/min, Addition regarding denosumab. A safety concerns creatinine Ͻ 3.0 mg/dL (265 ␮mol/L), no change in no change in dosage, infusion time, or interval of pamidronate or change in serum creatinine dosage, infusion time, or interval of pamidronate or zoledronic acid administration is required. Use of bone-modifying clearance threshold. Last sentence zoledronic acid is required. Use of these agents among patients with reduced renal function has been of 2003 recommendation taken out. bisphosphonates among patients with worse incompletely assessed. The packet insert of zoledronic acid Term changed from bisphosphonates function has been minimally assessed. provides guidance for dosing when baseline serum creatinine to bone-modifying agents. Infusion times Ͻ 2 hours with pamidronate or Ͻ 15 clearance is > 30 and < 60 mL/min. minutes with zoledronic acid should be avoided. Infusion times Ͻ 2 hours with pamidronate or Ͻ 15 minutes with The Panel recommends that serum creatinine should zoledronic acid should be avoided. be monitored prior to each dose of pamidronate or The Panel recommends that serum creatinine should be monitored prior zoledronic acid, in accordance with FDA-approved to each dose of pamidronate or zoledronic acid, in accordance with labeling. Serum calcium, electrolytes, phosphate, FDA-approved labeling. Serum calcium, electrolytes, phosphate, magnesium, and hematocrit/hemoglobin should magnesium, and hematocrit/hemoglobin should also be monitored also be monitored regularly but there is no regularly. The risk of hypocalcemia with denosumab dosed at 120 evidence upon which to base a recommendation mg every 4 weeks has not been evaluated in patients with a creat- for time intervals. inine clearance < 30 mL/min or receiving dialysis. Monitor for In contrast to multiple myeloma patients, there hypocalcemia in patients with impaired creatinine clearance. currently are no data to support routine There is no evidence to guide the interval for monitoring serum assessments for albuminuria in patients with calcium, electrolytes, phosphate, magnesium, and hematocrit/hemoglo- breast cancer. bin with denosumab, pamidronate, or zoledronic acid. Recommendation 3B: ONJ N/A ONJ is an uncommon but potentially serious condition associated New recommendation with the use of bone-modifying agents. The Update Committee concurs with the revised FDA label for zoledronic acid and pamidronate and the FDA label for denosumab and recommends that all patients with cancer receive a dental examination and necessary preventive dentistry prior to initiating therapy with inhibitors of osteoclast function unless there are mitigating factors that preclude the dental assessment. These recommendations should be observed whenever possible. While receiving inhibitors of osteoclast function, patients should maintain optimal oral hygiene and, if possible, avoid invasive dental procedures that involve manipulation of the jaw bone or periosteum. Although most cases of ONJ have occurred in patients treated with IV bisphosphonates and bone-modifying agents who underwent an invasive dental procedure, cases have occurred spontaneously and have been reported in patients treated with other bone-modifying agents, including oral bisphosphonates and direct osteoclast inhibitors. (continued on following page)1224 © 2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
  • 5. Breast Cancer Bone-Modifying Agents Update Executive Summary Table 1. Summary of 2011 Recommendations (continued) Recommendation Category 2003 Recommendations 2011 Recommendations Change Recommendation 4: The Panel suggests that once initiated, IV The Panel suggests that once initiated, bone-modifying agents be (Unchanged in substance from 2003) Optimal duration bisphosphonates be continued until evidence of continued until evidence of substantial decline in a patient’s general Term changed from bisphosphonates substantial decline in a patient’s general performance status. The Panel stresses that clinical judgment must to bone-modifying agents. performance status. The Panel stresses that clinical guide what constitutes a substantial decline. There is no evidence judgment must guide what is a substantial decline. addressing the consequences of stopping bone-modifying agents after There is no evidence addressing the consequences one or more adverse skeletal-related events. of stopping bisphosphonates after one or more adverse skeletal events. Recommendation 5: For breast cancer patients who have evidence of bone For patients with breast cancer who have evidence of bone destruction on Addition of new bone-modifying agent. Optimal intervals destruction on plain radiographs, IV pamidronate 90 plain radiographs, denosumab 120 mg subcutaneously every 4 The second-to-last sentence of 2003 between dosing mg delivered over 2 hours or zoledronic acid 4 mg weeks, IV pamidronate 90 mg delivered over 2 hours, or zoledronic recommendation is in over 15 minutes every 3 to 4 weeks is acid 4 mg over 15 minutes every 3 to 4 weeks is recommended. Recommendation 1 of 2011 recommended. There is insufficient evidence recommendations. relating to efficacy to support one bisphosphonate The last sentence from 2003 over the other. For each of the guidelines, clinical recommendation applies to all judgment should also take into consideration the recommendations. patient’s general performance status and overall prognosis. Recommendation 6: Role of The Panel recommends that the current standards of The Panel recommends that the current standards of care for cancer bone Change in timing of pain management. bone-modifying care for cancer pain management must be applied pain management be applied at the onset of pain, in concert with Term changed from bisphosphonates agents in pain control throughout bisphosphonate therapy and are the initiation of bone-modifying agent therapy. This is required by to bone-modifying agents. required by good clinical practice. These standards good clinical practice. The standard of care for pain management of care for pain management include analgesics, includes the use of nonsteroidal anti-inflammatory agents, opioid and corticosteroids, interventional procedures, nonopioid analgesics, corticosteroids, adjuvant agents, interventional nonsteroidal anti-inflammatory agents, systemic procedures, systemic radiopharmaceuticals, local radiation therapy, and radiopharmaceuticals, and local radiation therapy. surgery. Bone-modifying agents are an adjunctive therapy for Among other therapeutic options, IV pamidronate cancer-related bone pain control and are not recommended as or zoledronic acid may be of benefit among women first-line treatment for cancer-related pain. IV pamidronate or with pain caused by bone metastases to relieve zoledronic acid may be of benefit for patients with pain caused by bone pain when used concurrently with systemic chemo- metastases and contribute to pain relief when used concurrently with therapy and/or hormonal therapy, because it was analgesic therapy, systemic chemotherapy, radiation therapy, and/or associated with a modest pain control benefit in hormonal therapy. Bone-modifying agents have been associated with a controlled trials. modest pain control benefit in controlled trials. Recommendation 7: The The use of the biochemical markers to monitor The use of the biochemical markers to monitor bone-modifying agent use (Unchanged in substance from 2003) role of biochemical bisphosphonate use is not suggested for routine is not recommended for routine care. Term changed from bisphosphonates markers care. to bone-modifying agents. NOTE. For each of the recommendations, clinical judgment should also take into consideration the patient’s general performance status, patient preferences,and overall prognosis. Italicized text indicates minor changes. Bolded text indicates substantive changes. Abbreviations: IV, intravenous; CT, computed tomography; MRI, magnetic resonance imaging; FDA, US Food and Drug Administration; N/A, not applicable; ONJ,osteonecrosis of the jaw.with a creatinine clearance of less than 30 mL/min or receiving dialysis recommends care in line with the FDA-approved labeling. The FDA-are at a greater risk of severe hypocalcemia than patients with normal approved labeling of denosumab, pamidronate, and zoledronic acid ad-renal function. vises that patients should maintain good oral hygiene, have preventive dental examinations before initiating therapy, and avoid invasive dentalClinical Question 3B procedures whenever possible.12-14 Good oral hygiene includes What are the ONJ safety concerns of bone-modifying brushing and flossing after meals and use of a fluoride mouth rinse.agent therapy? The Update Committee, by consensus, suggests that in the setting Literature update and discussion. This recommendation is new of invasive dental procedures, it is advisable, whenever possible toto the guideline. ONJ is defined as an area of exposed bone in the delay the starting of therapy with bone-modifying agents until themaxillofacial or mandibular region that does not heal within 8 weeks initial bone healing process of the tooth socket bone has taken place. Ifafter identification by a health care provider, in a patient who was an invasive manipulation of the bone underlying the teeth is clinicallyreceiving or had been exposed to a bisphosphonate administered indicated before starting bone-modifying agent therapy, the Updateorally or IV and had not had radiation therapy to the craniofacial region. Committee consensus opinion is that initiation of bone-modifyingThe exposed bone is necrotic. Risk factors for ONJ include both bisphos- agent therapy should be ideally delayed for 14 to 21 days to allow forphonate type and duration of exposure, with the risk of ONJ increasing wound healing, if the clinical situation permits.with the higher potency drugs (zoledronic acid) and a longer duration of There were no RCT data to provide support for this recommen-therapy. The risk for ONJ occurs with denosumab, pamidronate, and dation. The evidence cited for this recommendation includes twozoledronic acid, whether administered alone or in sequence with other cohort studies, one case-control study, one chart review, two single-bone-modifying agents. The true incidence, prevalence, and etiology of institution experiences, product labels, and position papers, taskforceONJ remain unknown and are the subjects of ongoing investigations. reports, and reviews and/or position papers from other specialty med- Although direct evidence of the best way to minimize the risk of ical or dental societies. Please refer to the full guideline update for aONJ during bone-modifying agent treatment is lacking, the guideline more extensive discussion of ONJ.www.jco.org © 2011 by American Society of Clinical Oncology 1225 Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
  • 6. Van Poznak et alClinical Question 4 ers of bone resorption may have an increased risk for SREs and poor What is the optimal duration of bone-modifying agent therapy outcomes. Markers of bone formation and bone resorption can befor patients with metastatic breast cancer? measured in the blood or urine. Osteoclast inhibition can decrease or Literature update and discussion. This recommendation remains normalize the markers of bone resorption. The association betweenunchanged from 2003. There were no new published prospective markers of bone metabolism as a surrogate of osteoclast activity andclinical trials comparing different durations of bone-modifying agent risk of SREs has been investigated. Although an association has beentherapy. In clinical trials, durations of therapy ranged from 12 weeks in observed, there are no prospective data supporting the use of bio-an early-phase trial of denosumab to 96 weeks for the bisphosphonates chemical markers for diagnosis, to predict SREs, or to monitor bone-and up to 34 months in the phase III trial of denosumab. These studies modifying agent therapy.do not provide data on the impact of either continuing or stopping The guideline reviews data on the following markers:bone-modifying agent therapy after a defined time course, the rate of N-telopeptide of type I collagen, C-telopeptide of type I collagen,change in SREs in study groups, or the impact of limited versus bone-specific alkaline phosphatase, osteocalcin, and amino-terminalsustained versus pulsed use of bisphosphonate therapy. propeptide of type I collagen. The markers were investigated for the There are no prospective clinical RCT data to support the con- primary purposes of monitoring, predictive value (including paintinuation of bone-modifying agent therapy beyond 1 year, especially reduction), and diagnostic accuracy.for patients who are expected to survive longer than 1 year. In addi- Although there have been several studies showing decreases in bonetion, the paucity of prospective data addressing long-term toxicities of resorption or formation markers after administration of bone-modifyingbisphosphonates does not permit a balanced evaluation of the risk/ agents, no RCTs on biomarkers in this setting have been published thatbenefit profile of any long-term bisphosphonate therapy. used SREs as a primary end point, and the studies’ designs do not permit conclusions about the clinical utility of these markers. Until the time thatClinical Question 5 properly defined marker studies demonstrate clinical utility, the use of What are the best intervals between dosing? biomarkers to guide or monitor bone-modifying agent therapy is not Literature update and discussion. This recommendation remains recommended outside of a clinical trial.unchanged from 2003. There was no new evidence to support achange because most trials have continued using intervals of every 3 to Special Commentary on the Role of Vitamin D4 weeks. Deficiency and Bone-Modifying Agents Concerns exist regarding the dosing interval and duration of Although many of the trials of bone-modifying agents have in-therapy. There are limited data on the local (bone surface) bisphos- cluded supplementation of calcium and vitamin D as part of thephonate drug concentrations and retention times. These factors are treatment regimen, there are insufficient data to support a recommen-determined by the cellular status of individual bone surfaces, which is dation for a specific level of supplementation. Optimal concentrationsaffected by the rate of bone turnover, which is influenced by prior of vitamin D for bone health have not been established and are likely tobisphosphonate therapy and the cancer itself. vary at different stages of life and in different clinical settings. Because of lack of new evidence, the expert consensus of the In the absence of definitive data, it is the Update Committee’sUpdate Committee was to continue to support the 2003 recom- expert consensus that if there are no contraindications to calcium andmendation. The Update Committee recognizes that clinical judg- vitamin D supplementation, then patients with breast cancer receivingment may dictate modifications to dose schedules for a variety of bone-modifying agents should receive them at doses and schedulespatient-specific indications. similar to those used in the clinical trials of the bone-modifying agents, both to support bone health and decrease the risk of osteoclast inhibi-Clinical Question 6 tion-induced hypocalcemia. What is the role of bone-modifying agents in control of painsecondary to bone metastases? Literature update and discussion. This recommendation remains LIMITATIONS OF RESEARCH AND SUGGESTIONS FORunchanged from 2003. Bone-modifying agents are an adjunctive ther- FUTURE RESEARCHapy for pain control. Pain or the manifestation of an SRE is notnecessary for the initiation of a bone-modifying agent in a patient with Little new data that were published since the 2003 guideline met thebone metastases from breast cancer. Zoledronic acid, pamidronate, systematic review inclusion criteria to address the majority of clinicaland IV and oral ibandronate have all been shown to reduce pain scores questions in this guideline. New questions have arisen for which there are(primarily based on the Brief Pain Inventory) and analgesic use in notyetsufficientdatatofullyaddressalloftheclinicallyrelevantquestions.patients in three RCTs, two cohort studies, and five analyses of data Therefore, further research is needed in many areas addressing the man-from RCTs reviewed for this guideline update. agement of metastatic breast cancer involving the bone, including the duration and intervals of delivery of bone-modifying agents. Compo-Clinical Question 7 nents of a loading strategy at initiation of bisphosphonate therapy and What is the role of biochemical markers of bone turnover to later stopping or altering the interval are being investigated clinically, butguide initiation of therapy in patients without a prior skeletal event, presently, there are no data to address the efficacy of such an approach forpredict treatment response, guide adjustments to bone-modifying any outcomes. Future trials may include investigation of pulse bone-agent therapy, or independently predict future fractures? modifying agent therapy. Additional data may enable the development of Literature update and discussion. This recommendation remains anindexofriskforSREs,andapatient’sindividualrisk/benefitcalculationunchanged. Patients with metastatic bone disease and elevated mark- mayguidebone-modifyingagenttherapy.Thereisaneedforclinicaltrials1226 © 2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
  • 7. Breast Cancer Bone-Modifying Agents Update Executive Summarythat explicitly compare different intervals between treatment with bone- those in vulnerable populations. Further discussion of patient-modifying agents to learn the effects on relevant clinical outcomes such as clinician communication and health disparities is available in theSREs, time to SRE, pain, or adverse events evaluated in this guideline. full guideline. Trials specific to whether patients with stage IV breast cancer andno bone metastases would benefit from initiating bone-modifying ADDITIONAL RESOURCESagents are needed. Stratification and analysis by such factors as sex,estrogen receptor/progesterone receptor status, human epidermalgrowth factor receptor 2 status, ethnic and racial status, and whether a The guideline, including evidence tables (Data Supplement), isgiven participant has bone-predominant disease versus visceral- available at www.asco.org/guidelines/bisphosbreast, along with adominant disease could help identify whether any of these factors are slide set and other resources. Patient information is available thererelevant in selecting the use of bone-modifying agents. In addition, and at www.cancer.net.more research is needed on denosumab and other new bone-modifying agents, the role of biomarkers in treatment selection and AUTHORS’ DISCLOSURE OF POTENTIALmonitoring, the role of calcium and vitamin D supplementation, CONFLICTS OF INTERESTcomparative effectiveness research, and how and when bone-modifying agents should be integrated with other therapies. Although all authors completed the disclosure declaration, the following In addition, although progress has been made in the years since the author(s) indicated a financial or other interest that is relevant to the subjectidentification of ONJ to characterize and define the toxicity, much re- matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; thosesearch remains to be performed to better determine and ameliorate risk relationships marked with a “C” were compensated. For a detailedfactors and to offer effective treatment for ONJ associated with bone- description of the disclosure categories, or for more information aboutmodifying agent therapy for breast cancer. Several ongoing and planned ASCO’s conflict of interest policy, please refer to the Author Disclosurestudiesaregatheringdataonincidence,riskfactors,andtreatmentofONJ. Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership: None Consultant or Advisory: Linda PATIENT-CLINICIAN COMMUNICATION AND Bosserman, Amgen (C), Roche (C); Catherine Van Poznak, Amgen (C); HEALTH DISPARITIES Gary Yee, Amgen (C), Roche (C) Stock Ownership: None Honoraria: Linda Bosserman, Abraxis BioScience, Amgen, Roche ResearchThe Update Committee stresses the importance of communicating Funding: Catherine Van Poznak, Amgen, Novartis Expert Testimony:risks and benefits of and the rationale expected for using bone- None Other Remuneration: Nonemodifying agents, including clarifying potential outcomes. TheUpdate Committee also suggests that clinicians give patients op- AUTHOR CONTRIBUTIONSportunities to share their expectations of treatment. In addition,awareness of disparities in access to care should be considered in Administrative support: Sarah Teminthe context of this clinical practice guideline, and health care pro- Manuscript writing: All authorsviders should strive to deliver the highest level of cancer care to Final approval of manuscript: All authors 4. Stopeck AT, Lipton A, Body JJ, et al: Deno- of skeletal complications in patients with advanced REFERENCES sumab compared with zoledronic acid for the treat- multiple myeloma or breast carcinoma: A random- ment of bone metastases in patients with advanced ized, double-blind, multicenter, comparative trial. 1a. Hillner BE, Ingle JN, Berenson JR, et al: breast cancer: A randomized, double-blind study. Cancer 98:1735-1744, 2003American Society of Clinical Oncology Guideline on J Clin Oncol 28:5132-5139, 2010 10. Rosen LS, Gordon D, Tchekmedyian NS, et al:the Role of Bisphosphonates in Breast Cancer. 5. 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Lipton A, Steger GG, Figueroa J, et al: Ex- Efficacy of ibandronate for the treatment of skeletal approved label: Zoledronic acid packet insert. http://tended efficacy and safety of denosumab in breast events in patients with metastatic breast cancer. www.accessdata.fda.gov/drugsatfda_docs/label/2009/cancer patients with bone metastases not receiving Eur J Cancer Care (Engl) 18:653-656, 2009 021223s018lbl.pdfprior bisphosphonate therapy. Clin Cancer Res 14: 8. Body JJ, Diel IJ, Lichinitser MR, et al: Intrave- 13. US Food and Drug Administration: FDA-approved6690-6696, 2008 nous ibandronate reduces the incidence of skeletal label: Xgeva (denosumab). http://www.accessdata 3. Fizazi K, Lipton A, Mariette X, et al: Random- complications in patients with breast cancer and .fda.gov/drugsatfda_docs/label/2010/125320s007lbl.pdfized phase II trial of denosumab in patients with bone metastases. Ann Oncol 14:1399-1405, 2003 14. US Food and Drug Administration: FDA-approvedbone metastases from prostate cancer, breast can- 9. Rosen LS, Gordon D, Kaminski M, et al: Long- label: Aredia, pamidronate disodium packet insert. http://cer, or other neoplasms after intravenous bisphos- term efficacy and safety of zoledronic acid com- www.accessdata.fda.gov/drugsatfda_docs/label/2008/phonates. J Clin Oncol 27:1564-1571, 2009 pared with pamidronate disodium in the treatment 020036s035lbl.pdf ■ ■ ■www.jco.org © 2011 by American Society of Clinical Oncology 1227 Downloaded from jco.ascopubs.org on May 19, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.

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